Md. Code Regs. 31.10.06.24

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.06.24 - Medicare Select Policies and Certificates-General Requirements

A. Applicability.

(1) This regulation applies to Medicare Select policies and certificates, as defined in Regulation .02 of this chapter.

(2) A policy or certificate may not be advertised as a Medicare Select policy or certificate unless it meets the requirements of this regulation.

B. The Commissioner may authorize an issuer to offer a Medicare Select policy or certificate pursuant to this regulation and § 4358 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 if the Commissioner finds that the issuer has satisfied all of the requirements of this regulation.

C. A Medicare Select issuer may not issue a Medicare Select policy or certificate in Maryland until its plan of operation has been approved by the Commissioner.

D. Required Filing of Plan of Operation.

(1) A Medicare Select issuer shall file a proposed plan of operation with the Commissioner and with the Secretary of the Department of Health and Mental Hygiene in a format prescribed by the Commissioner.

(2) The plan of operation filed with the Commissioner shall contain at least the following information:

(a) A statement or map providing a clear description of the service area;

(b) A description of the grievance procedure to be utilized;

(c) Copies of the written information proposed to be used by the issuer to comply with Regulation .25B of this chapter; and

(d) Any other information requested by the Commissioner.

(3) The plan of operation filed with the Secretary of Health and Mental Hygiene shall contain, at a minimum, the following information:

(a) Evidence that all covered services subject to restricted network provisions are available and accessible through network providers, including a demonstration that:

(i) Services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation, and after-hours care;

(ii) The number of network providers in the service area is sufficient, with respect to current and expected policyholders, either to deliver adequately all services that are subject to a restricted network provision or to make appropriate referrals;

(iii) There are written agreements with network providers describing specific responsibilities;

(iv) Emergency care is available 24 hours per day and 7 days per week; and

(v) In the case of covered services that are subject to a restricted network provision and are provided on a prepaid basis, there are written agreements with network providers prohibiting the providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate;

(b) A statement or map providing a clear description of the service area;

(c) A description of the quality assurance program, including:

(i) The formal organizational structure;

(ii) The written criteria for selection, retention and removal of network providers; and

(iii) The procedures for evaluating quality of care provided by network providers, and the process to initiate corrective action if warranted; and

(d) A list and description, by specialty, of the network providers.

(4) In determining the reasonable promptness of services provided with respect to geographic location in §D(3)(a)(i) of this regulation, the geographic availability shall reflect the usual travel times within the community.

(5) In determining the reasonable promptness of services provided with respect to hours of operation and after-hours care in §D(3)(a)(i) of this regulation, the hours of operation and availability of after-hours care shall reflect usual practice in the local area.

(6) With respect to the requirements in §D(3)(a)(v) of this regulation that prohibit providers from billing or otherwise seeking reimbursement from or recourse against any individual insured under a Medicare Select policy or certificate, the prohibition is not required to be applied to supplemental charges or coinsurance amounts stated in the Medicare Select policy or certificate.

(7) The Secretary of the Department of Health and Mental Hygiene shall notify the Commissioner in writing after the determining that the plan of operation filed by the issuer is acceptable.

E. Required Filing of Changes to Plan of Operation.

(1) In General.

(a) A Medicare Select issuer shall file with the Commissioner any proposed changes to the plan of operation, except for changes to the list of network providers, prior to implementing the changes.

(b) Changes shall be deemed approved by the Commissioner after 30 days unless specifically disapproved.

(2) A Medicare Select issuer shall file an updated list of network providers with the Secretary of the Department of Health and Mental Hygiene at least quarterly.

(3) The Secretary of the Department of Health and Mental Hygiene shall notify the Commissioner in writing if the updated list of providers submitted in accordance with §E(2) of this regulation ceases to meet the criteria set forth in §D(3)(a) of this regulation.

F. A Medicare Select policy or certificate may not restrict payment for covered services provided by nonnetwork providers if:

(1) The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury, or condition; and

(2) It is not reasonable to obtain services through a network provider.

G. A Medicare Select policy or certificate shall provide payment for full coverage under the policy for covered services that are not available through network providers.

H. A Medicare Select issuer shall comply with reasonable requests for data made by state or federal agencies, including the United States Department of Health and Human Services, for the purpose of evaluating the Medicare Select Program.

Md. Code Regs. 31.10.06.24

Regulation .24 adopted as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; adopted permanently effective April 1, 2002 (29:6 Md. R. 570)